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�V SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> POBrOFFICE USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. -7f..Z� <br /> R THIS PERMIT SIRES 1 YEAR FROM DATE ISSUED Dace Issued l-/�;7Z <br /> - (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local stealth District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION r t <br /> CENSUS TRACT <br /> Owner's Name Phone <br /> Address 9 <br /> � 3 � City <br /> e --s sr <br /> Contractor's Name 0A 14 License # J_W2 iPhone pj-W <br /> i <br /> TYPE OF WORK (Check): NEW WELL &-7 DEEPEN I-7 RECONDITION /-7 , DESTRUCTION <br /> PUMP INSTALLATION / / PUMP REPAIR /-7 PUMP REPLACEMENT /7Other <br /> 3 � <br />.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY r <br /> SEWAGE DISPOSAL FIELD CESSPOOL/.SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL'— <br /> PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial �_ Cable Tool Dia. of Well Excavation , <br /> Domestic/privateDrilled Dia. of Well Casing f' c <br /> w� Domestic/public -j-, .Driven Gauge df;.-Casing p Q. T . <br /> Irrigation 'tG'ravel Pack Depth of Grout, Seal <br /> Cathodic Protection Rotary Type of Grout`' <br /> i. Disposal Other. - Other Information <br /> s Geophysical. "�"`"�"' <br /> ' '► 'Surface Seal Installed By; /Y;Z- <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump [ H.P. r <br /> 'UMP REPLACEMENT: /�/ State-,Work Done :A <br /> PUMP, `.REPAIR:r " 4-7 ,.State Joik.Done- <br /> - <br /> ES;TRUCTION OF WELL: Well. Diameter;;,;. Approximate Depth <br /> Describe Material and-Procedure ' -- <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local-,Hea1th District <br /> and the State of California-pertaining to'-or-regulating-iwel�".coni'stru6ti6n. Within FIFTEEN' DAYS <br /> after completion of guy work on a new well, I will furnish the San .Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the..well in-use.. The above <br /> information is true to the best of my knowledge and belief. I WILL CALL FOR A "GROUT INSPECTION <br /> PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> SIGNED TITLE' <br /> KL (DRAW PLOT PLAN ON REVERSE SIDE <br /> FOR DEPARTMENT USE ONLY ' <br /> PHASE I r <br /> APPLICATION ACCEPTED BY DATE t� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION —1 F INSPECTWN <br /> INSPECTION BY DATE INSPECTION- BY PATE ,? <br /> .. �, <br /> E H 1426 Rev. 1-74 1-74 2M <br />